Beruflich Dokumente
Kultur Dokumente
Dental Insurance
Everyone Deserves
A Healthy Smile
SECDEN-BR-TX-FLIC-1014
SecureDental Plan
Premium Plan
Deductibles $50 per person, $150 per family1,6
Coinsurance
PPO (In-Network)
Non-PPO (Out-of-Network)
Basic Care
Major Care
Orthodontic Care
100%2
80% 4
70%5
70%5
80%
60%
50%
50%3,5
2,3
3, 4
3, 5
$1,500
$400
Preventive
Care
Basic Care
Major Care
PPO (In-Network)
100%2
70% 4,
60%5
Non-PPO (Out-of-Network)
80% 2,3
50%3, 4
50%3, 5
Orthodontic Care
Discounted Services at a Contracted Dentist7
Saver Plan
Deductibles $50 per person, $150 per family1,6
Coinsurance
Preventive
Care
Basic Care
PPO (In-Network)
100%2
60% 4
Non-PPO (Out-of-Network)
70% 2,3
50%3, 4
Major Care
Orthodontic Care
Benefits are subject to the Calendar Year Deductible and Calendar Year Maximum specified above per Covered Insured
One during a consecutive six months per Insured
One treatment per tooth every consecutive thirty-six months per Insured
2
3
SecureDental Plan
Orthodontic Care
2
3
SecureDental Plan
Termination
A Covered Insureds coverage ends on the earlier of: the premium
due date in the month following the date the Group Policy is
terminated by the Group Policyholder; the due date of any unpaid
premium, subject to the grace period; the date You terminate
coverage by notifying Us in writing of the date You desire coverage
to terminate and specify the Covered Insured whose coverage is to
terminate; the date We receive due proof that fraud or intentional
misrepresentation of material fact existed in applying for the
Certificate or in filing a claim for Benefits under the Certificate;
with respect to Your spouse who is covered under the Certificate,
the premium due date in the month following the effective date of
Your divorce decree, annulment or court approved separation; the
date You cease being a member of the group to whom the Group
Policy is issued; the premium due date in the month following the
earlier of: (a) the date the Covered Insured attains age 65; or (b) the
date the Covered Insured becomes eligible or qualified for Benefits
under Medicare or any other government insurance plan (except
Medicaid); or with respect to Your child(ren) who is covered under
the Certificate, the premium due date in the month following such
Covered Insureds 25th birthday. Coverage will not end if such child
is dependent on You for support and maintenance and incapable
of self-support because of a mental handicap or physical disability.
Such coverage will continue as long as the Certificate stays in
force and the child remains dependent. Proof of such handicap or
disability must be furnished to Us within 31 days prior to the child
reaching the limiting age, and thereafter upon Our request, but not
more frequently than annually after the 2 year period following the
childs attainment of the limiting age.
Renewability
You may renew the Certificate on any renewal date, subject to the
Termination of Coverage provision, unless We give You at least
ninety (90) days written notice that We are refusing to renew. We
may refuse to renew only if We do so on Certificates of this form on a
Class Basis in the state where Your Certificate was issued. Our refusal
to renew can only be effective on a premium date and the coverage
under the Certificate will then terminate at 12:01 A.M. local time
where You live. To renew, pay the renewal premium at the interval(s)
available to You at the time of renewal.
Coordination of Benefits
The Dental Certificate contains a Coordination of Benefits provision,
which describes how Benefits will be payable. Benefits payable under
the Certificate may be reduced when a Covered Insured has more
than one plan, depending on whether this coverage is a primary or
secondary plan. The Certificate contains a Coordination of Benefits
provision which outlines the order of benefit determination rules for
determining if coverage is primary or secondary.
SecureDental Plan
LIMITATIONS
In addition to any other provisions of the Certificate, Benefits and coverage are limited as follows:
The amount of the Calendar Year Maximum Dental Benefit Per Insured shall not exceed the sum of $500 for the Saver Plan, $1,000
for the Saver Plus Plan, and $1,500 for the Premium Plan, with an additional $400 Calendar Year Maximum Orthodontic Benefit
per Insured and Lifetime Maximum Orthodontic Benefit Per Insured of $1,000 on the Premium Plan.
No Benefits are payable under the BASIC DENTAL CARE provision unless they are incurred at least six (6) months after the
Issue Date.
No Benefits are payable under the MAJOR DENTAL CARE provision unless they are incurred at least twelve (12) months after the
Issue Date
No Benefits are payable under the ORTHODONTIC DENTAL EXPENSES provision unless they are incurred at least twelve (12)
months after the Issue Date.
Non-Covered Items
Coverage under the Certificate is limited as provided by the definitions, terms, conditions, limitations, and exclusions contained in each
and every section of the Certificate. In addition, the Certificate does not provide coverage for professional and dental services Provided
to an Insured or any payment obligation for Us under the Certificate for any of the following, all of which are excluded from coverage:
Any expenses for treatments, care, procedures, services or
supplies which are not Covered Dental Expenses or Covered
Orthodontic Expense incurred by a Covered Insured, and
which are not specifically enumerated in the COVERED
DENTAL EXPENSE or COVERED ORTHODONTIC EXPENSE
section of the Certificate;
Treatments, care, procedures, services or supplies received
before the Certificate Issue Date;
Covered Dental Expense or Covered Orthodontic Expense
received after the Certificate terminates, regardless of when
the condition originated;
Covered Dental Expenses that exceed the amount of the
Calendar Year Maximum Dental Benefit Per Insured;
Covered Orthodontic Expenses that exceed the amount of
the Calendar Year Maximum Orthodontic Benefit per Insured.
Prescription Drugs;
Any treatments, care, procedures, services or supplies which
are not specifically enumerated in the COVERED DENTAL
EXPENSES or COVERED ORTHODONTIC EXPENSE sections
of the Certificate and any optional coverage rider attached
to the Certificate;
any professional services for which the Insured and/or any
covered family member are not legally liable for payment;
any professional services for which the Insured and/or any
covered family member were once legally liable for payment,
but from which liability the Insured and/or family member
were released;
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Non-Covered Items (contd)
Treatment received outside of the United States;
Treatment on or to the teeth or gums for cosmetic purposes,
including charges for personalizations, characterizations or
Dentures;
SecureDental Plan
Notes
GRP-P-13-FLIC
The underwriting insurance company in Your state has agreed to perform
or cause to be performed certain monthly administrative services on
behalf of the association including the collection of certain enrollment
fees and monthly membership dues on behalf of the association and
transmission to the association of monthly membership census data.
The underwriting insurance company in Your state is paid a monthly
fee by the association for these administrative services.